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Leveraging EHR for Opioid Stewardship
Session BP1, February 11, 2019
Todd Burstain, MD CMIO Ochsner Health Systems
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Todd Burstain, MD
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Opioid Epidemic Review
Analytic Reporting
Standardized Prescribing
Opioid Risk Tool
Morphine Equivalent Daily Dose
Registries for Chronic Users
Health Maintenance Build
PMP Link
Pain Management Innovations
Outcomes
Agenda
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Outline analytic tools and role in changing prescribing behavior
Discuss role of Opioid Risk Tool in opioid stewardship
Outline basis for Opioid Registry development
Discuss how Health Maintenance tools can leverage stewardship
Outline how EHR can link to PMP data
Learning Objectives
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The Start of an Epidemic
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The Opioid Crisis Nationally and Locally
63,632 Americans died in 2016 from Drug Overdose
66% from prescription/illicit opioids
Prescription opioid overdose death rate up 10.6% (2015-6)
21-29% of patients given opioids for chronic pain end up
misusing them
80% of patients abusing Heroin began with abusing
prescription opioids
2003 to 2013 Neonatal Abstinence Syndrome in La increased
by 380%
Economic cost to US over $78 billion/year
Deaths from overdose > homicide in Orleans Parish 2016
6
th
highest rx/pt in US in LA at 1.02 rx/person in state
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Overall Strategy
Build Governance Structure
Educate Providers and Patients
Why is it important
What is best practice
Provide analytic feedback data
Target Key areas
Build Best Practice into Epic
Hardwire workflows
Intelligent Decision Support
Develop Community Resources
Report on Success of Intervention
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The Ochsner Opioid Stewardship Team
Team Lead
Strategic Program
Manager
Opioid Stewardship Committee
Hospital Opioid
Stewardship
Clinic Opioid
Stewardship
ED Opioid
Stewardship
Pain Treatments
Urgent Care Opioid
Stewardship
Dependency Treatment
and Recovery
Opioid Diversion
Service Line Opioid
Management
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Patient and Provider Education
10
First Blinded data, then remove the blindfolds
40% decline in opioid rxs
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MEQ/Rx and % following guideline (3d/rx)
ED Alignment To Guidelines
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Initial Resistance: HCAHPS
Physicians Who Prescribe Less Have
Same Patient Experience
70
75
80
85
90
95
100
0% 5% 10% 15% 20% 25% 30% 35% 40%
Patient Experience Mean Score
Opioid Prescribing Rate
Opioid Prescribing Rate vs. Press Ganey Mean Score by Physician
To Ease Fears, Removed Patient Satisfaction for Pain Despite
Lack of Correlation
13
Expand the Pilot Inpatient OB discharges
Hardwire into D/C Ordersets
OB Adherence to Guideline (3d/rx)
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Not just less prescribing, better prescribing
Identify low risk vs high risk patients
What did literature say
Design best way to monitor patients getting opioids
Minimize risk
Monitor for misuse
Communicate expectations with patients
Hardwire best practices into workflow
Monitor results and provide feedback
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Can we identify who is at risk for misuse?
Opioid Risk Tool Questionnaire University of Utah
5.6% of low risk patients developed misuse of opioid
90.9% of high risk patients developed misuse of opioids
Coefficient 0.82 for males, 0.85 for females
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Custom Built Opioid Management Activity in Epic
Minimize End User Data
Entry
Auto Flags based on
Problem List
Auto Flags based on
Family Hx
Auto Flags based on
Social Hx
Differentiates between
validated and non-
validated scores
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Opioid Risk Tool Report and Explanation
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Opioid Management Tool - Resources
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Direct Links to Patient Assessment
PEG 3 and PHQ 4
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Tracking over Time
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Displaying the Score to End User
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How strong is that prescription?
Concept of Morphine Equivalents Daily
Dose (MEDD)
Issues of prn sig on prescriptions
Complexities of Methadone in MEDD
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Best Practice of Care Based on Risk
Separating acute from chronic users
Minimizing Risk
Naloxone Prescription
Opioid Risk Tool Evaluation
Monitoring Compliance
Urine Drug Screens
Communicating Expectations with Patients
Pain Contracts
Using tools End Users Familiar With Health Maintenance
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Separating Acute from Chronic Users
Rule based on 3 active rx for opioid in last 4 months
Age > 18 (had age limit of 80 but removed this later)
Not on hospice care
No active diagnosis of cancer
Inclusion rule added patients to registry based on risks
Low risk ORT score low, no hx of substance abuse,
MEDD<90, no concomitant benzodiazepine use
Med risk ORT score medium, no hx of substance abuse,
MEDD<90, no concomitant benzodiazepine use
High risk ORT score high, or hx of substance abuse or
MEDD>=90 or concomitant benzodiazepine use
Vetted results with sample end users to confirm accuracy
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Send to: All patients receiving
opioids for 3 of the last 4 months
Once we figure out the roll out
date we can back into this
Send to: All patients receiving
opioids from a provider who no
longer works for us
Ongoing basis
Delivery Mechanism: Mail to
patients directly
Each Primary Care location
print the letter on their
letterhead so their patients have
the clinic number readily
available at the top of the letter
Education: Notify Providers at
Primary Care Council meeting (prior
to letter “going live”)
Tracking: Track letter delivery/sent
through MyChart and Letters Tab
Patient Letter
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Breakdown of Chronic Opioid Users
5724
506
1832
8062
5272
473
1771
7516
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Low Risk Med Risk High Risk Total
Chronic Opioid Use Patients
Jun-18 19-Jan
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Breakdown of Chronic Opioid Use by Age
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
18-30 31-40 41-50 51-60 61-70 71-80 >80
Jun-18 Jan-19
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Various Diagnosis among Chronic Opioid Users
26.80%
35.60%
2.80%
1.90%
3.40%
0.70%
2.10%
22.40%
10.60%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
72% had some pain disorder on Problem List
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Narcotic Prescribed and Benzodiazepine Use
0%
10%
20%
30%
40%
50%
60%
70%
% Patients on Rx in last 6 months
"June 18"
"Jan 19"
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Health Maintenance Topic Rules
Low Risk
ORT completed
Pain Contract signed
Medium Risk
Same as low
UDS yearly
High Risk
Same as low
UDS every 6 months
Naloxone rx yearly
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Building Out Health Maintenance Rules
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Build HM into HM Overdue SmartSet
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Integrating Pain Contract Documents
Created document type of pain contract for scanned documents
Fax form with standard contract available via one click link
Trained staff and HIM to scan documents into media tab
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Monitor for Misuse with PMP Link
Identify vendor for HIE Appriss
Develop call out protocol and matching criteria
Mark in Employee record who has PMP access
One click solution
Information Technology Academy Journal 4/18
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In application PMP report viewing
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Innovative Approaches to Pain
Treatment
Healthy Back Program
10 Week Program- Two Times
Per Week
Patients Reported a 62.5%
Decrease in Pain After 10
Weeks of Treatment
Medicaid Grants to Provide
Services Not Usually Covered:
PT
Paravertebral Facet Joint
Blocks
Virtual Reality to Reduce Initial
Exposure to Opioids
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Functional Restoration Program
Outpatient, Multidisciplinary,
Three-Week Program Includes:
Pain Medicine, Pain Psychiatry
Specialists, Physical & Occupational
Therapists, Social Workers & Nutrition
Coaches
Focus on Reclaiming Function &
Patient-Centered Goals
Program Currently Completing
6
th
Cohort, 30-days After
Program, Patients Report:
51% Decrease in Disability Due to Pain
32% Improvement in Sleep
63% Improvement in Mood
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Opioid Free Cases
Opiate Free Protocol
Cases > 2 Hours
Pre-operative IV
Acetaminophen and IV
Ibuprofen
Started with Colorectal &
Urology Procedures
Other Procedures to Limit
Opioid Use: Knee & Hip
Replacements
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Expanding Opioid Use Disorder Treatment
Options
Our New Psychiatric Hospital- River Place Behavioral
Health- Will Open a Dual Diagnosis Unit in 2018
Offering Detoxification and Induction with Buprenorphine
for Opioid Dependent Patients with Acute Psychiatric
Issues
Psychiatry's Suboxone Program (OchMAT) is Underway
Adding Additional Support to Capture a Greater Range of
Disease Severity.
Intensive Outpatient Program for Substance Use
(Addictive Behavior Unit) is Streamlining its Services for
Opioid Dependent patients
Providing Easier Access to Outpatient Suboxone
Treatment.
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Outcomes
Prescription rates
Guideline Compliance
PMP registration
Best Practice Health maintenance
ORT
Pain Contracts
UDS
Naloxone Rx
Expansion
Concomitant benzodiazepine usage
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ED Prescription Data
(Began at 105 MEQ/rx and 50% guideline alignment (3d/rx))
% Alignment to Guideline
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OB Prescription Data
Alignment to Guideline (3d/rx)
% Alignment to Guideline
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Urgent Care Prescription Data
Alignment to Guideline (3d/rx)
% Alignment to Guideline
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System Wide Prescription Data
% Patients Seen in Office/ED/Hosp given Opioid
20,400 fewer patients on Opioids
ED Reporting
HM Go live
MEDD Go live
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System Wide Prescription Office Visit
Only
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System Wide Prescription ED Only
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PMP: Provider Registration 2018
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Jan Feb March April May June July Aug Sep Oct Nov Dec
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Health Maintenance Outcomes Low Risk
24.0%
21.1%
14.0%
29.9%
26.5%
16.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
ORT completed Pain contract Both done
18-Jun 19-Jan
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Health Maintenance Outcomes Med Risk
64.0%
36.6%
31.0%
18.2%
73.9%
43.9%
39.6%
23.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
ORT completed Pain contract Urine Screen All 3
18-Jun 19-Jan
50
Health Maintenance Outcomes High Risk
35.1%
24.6%
17.1%
15.3%
4.8%
45.8%
33.4%
21.6%
15.9%
4.5%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
18-Jun 19-Jan
51
Patients Getting Urine Drug Screening
33% increase
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Patients with Rx for Naloxone
96% increase
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Todd Burstain, MD
CMIO, Ochsner Health Systems
todd.burstain@ochsner.org
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